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The Bipolar Child and Anxiety

27 Mar

 

Anxiety is often the first symptom that is clearly identified in children who have bipolar illness. It might be intense separation anxiety, OCD type behaviors, or frightening dreams, to name a few possible symptoms.  But in bipolar disorder the mood instability adds an additional layer of complexity and intensity. This is not an easy diagnosis to make.  There is controversy surrounding this diagnosis, which keeps company with other disorders, to add to the confusion. The term bipolar refers to a disruption in the regulation of moods, so that rather than maintaining a relative steady state, the child swings between periods of depression and periods of mania or elation. And sometimes children are in a mixed state that contains elements of depression and mania, where a pronounced irritability might be seen. Suicidal ideation and hypersexuality can also be part of the picture.  This condition is viewed as primarily a biologically based disorder with a strong genetic component.

There are some distinctive features in the experience of anxiety for a child who has to struggle with a mood disorder. What powers the child’s   experience of anxiety is the sheer intensity with which they experience their moods; they seem to have no serviceable “ brakes”, or feel that there is any control over mood. It is the internal experience of intensely fluctuating moods that produces the feeling of danger and lack of safety. But there is more. This intensity also comes with disturbing images. Many children with bipolar illness have truly horrendous nightmares. While all children will have a nightmare on occasion, they usually wake up before the robber enters the room.  For a bipolar child, however, it doesn’t stop there. The dream unfolds in the worst graphic detail. And the vividness of the dream may continue to preoccupy the child during the day, and then he/she may dread going to bed lest another similar dream occurs. The intensity of moods can create hallucinations and other impairments in reality testing.   A good description of having bipolar disorder as a child can be found in Intense Minds: Through the Eyes of Young People with Bipolar Disorder by Tracy Anglada, whom I also interviewed for my iTunes podcast,  “Your Anxious Child: 5 Minute Solutions”.

Although the experience of anxiety is pervasive in bipolar disorder, the treatment priorities are different from the standard treatment of anxiety. In the standard treatment of anxiety, priority is placed, as in cognitive behavior therapy, on facing the fear and decreasing avoidance. Medication plays a secondary role in treatment of the more standard anxiety disorders, turning down the intensity of anxiety when necessary so that the child can participate in therapy.  In bipolar disorder, medication management of moods is the first priority of treatment, and this is a situation where a child psychiatrist is the key player. Psychological interventions will center more on helping the child maintain contact with reality and creating a sense of safety. These are children who may, while awake or asleep, see scary images that are not there.  Thus, stabilization is often the first priority. This is not to say that we don’t help the child with bipolar disorder learn that he can be upstairs without a parent or talk back to that scary image in the closet or draw that scary dream and potentially change it. But we need a certain stability in moods as a platform to tackle these various worries. These children really benefit from a team approach that can address their diverse needs. They often have pronounced sensory issues which may benefit from sensory-integration therapy. There may be problems in executive functioning that require attention in school. Bipolar disorder is a complex disorder that requires a careful diagnosis, and while anxiety is very prevalent it is not the core feature.

Oh she will be fine

20 Dec

“Oh She will be fine”  Edward H. Plimpton, PhD

 

Recently, you expressed a concern about your anxious child to a friend, or perhaps a pediatrician or teacher, and were told “Oh, she will be fine, it is probably just a phase”. Perhaps. A lot of parenting involves learning what to fuss over and what to let go.  Mark Twain once said “I’ve had a lot of worries in my life, most of which never happened”.  A wise statement, implicit in the well-intentioned reassurances from friends and professionals. It is invaluable to draw upon the experience of others who know how certain behaviors and feelings can change and unfold over time. It is not unusual for a child to tearfully and bitterly protest about being dropped off at daycare or school, and then to have the teacher report that she was fully and happily engaged ten minutes later. Experience can teach us not to be too reactive to the present moment, especially since excessive parental reactions foster anxiety and other problems in children.  And children can be incredibly resilient under difficult circumstances in seeking out what they need to prosper and thrive. So there is a lot of truth to the simple statement that “she will be fine”.

“She will be fine”, however, can also be an empty and misleading reassurance. Many a parent has sensed that something was not quite right, only to be dismissed with “it is just a phase,” with the underlying message that it is simply the concern of a nervous parent. But life is uncertain, there is no crystal ball, and parenting is definitely an exercise in tolerating uncertainty. Sometimes “she will be fine” is the response of someone who doesn’t have the knowledge to say anything else, or who doesn’t want to share the uncertainty and doubt. It is, after all, quite difficult to tolerate being in a state of uncertainty. But there is good reason not to dismiss your concerns about your child, whom you know better than anyone else. It may seem obvious, but the reason you know your child so well is that you have a sense of her behavior over time, and her daily rhythms, and the way that she is unique. Any one snapshot of your child, say in school or in the doctor’s office, is only a partial view. ADHD, for instance, is not properly diagnosed by just observing a child in a doctor’s office, but rather by looking at her in several different settings.  Anxious children are well known to keep a low profile in school and in other settings outside of the home.  They can keep it together in school, only to fall apart when they are safe with a parent. The disparity in terms of how your child is viewed does not mean that either you or the friendly commentator is incorrect–you just have access to different time samples. And having a sense of a child across time puts a parent in a privileged position.  So your knowledge of your child’s behavior over time is an invaluable piece of information which should not be discounted.

When faced with a strong intuition that something is not right, one thing a parent can do is to keep asking questions and  sharing experience. This may help clarify the nature of your concern and help sort out what is just a phase and what is a roadblock to your child’s development. Parenting can be complicated, and there is a lot of sorting out to be done, which is why we talk about our kids so much. As the famous pediatrician Benjamin Spock said many years ago, “Trust yourself. You know more than you think you do.”

copyright@Edward H. Plimpton, PhD

Why Doesn’t My Child Want to Get Help?

21 Aug

Your home is nice, but sometimes you would like to go out for a change of scenery, perhaps a game of mini-golf or dinner at a family oriented restaurant. Is that really asking too much? Well actually, yes, says your anxious child, home is really better. And realizing how much your child’s anxiety is affecting the entire family, limiting positive family activities, you decide to get help. But there is one problem: your child doesn’t want any help and indicates in no uncertain terms that it is not happening. What to do? The situation is getting urgent and your child won’t budge. Here are three items for your consideration.

First, it may be that you have a child whose first response to anything new is an emphatic “no” or perhaps a dramatic scream of bloody murder–it doesn’t matter whether it is mini-golf or a scheduled visit to a therapist. But given some time, he will come around when he senses you are not going to give up. So time and a clear parental directive is what is needed for the child to wrap his head around this new turn of events. Even though an anxious child’s first reaction to a suggestion to do something different might always be a “no”,  often she can end up going to the birthday party and having fun. But sometimes  that doesn’t happen, so of course, we also want to take the time to see if there are some specific concerns we didn’t know about.

Second, the problem may be that it just feels too hard to talk about those anxious feelings. For some children the concern may be that talking about their fears will make them more real or make them come true. This may be a reflection of the magical thinking that can color children’s mental processes. Saying something out loud, they fear, will somehow make the fear more likely to happen. Even adults will sometimes say “don’t say that,” as if silence offers some protection. Another way in which it may be hard to tolerate talking about worries is that some children are extremely self-conscious and tolerating any attention is rather painful.  Or it may be that your child is just very emotionally reactive for any number of reasons, and tolerating any feelings is very hard. And for this type of child, any new situation needs to be introduced slowly so they can build their tolerance or capacity to deal with it.

Third, if your child shows little motivation to change or to deal with an obvious problem, it may be that you have been too helpful and accommodating. It is only natural as a parent, when your child is in distress, to want to provide comfort and reassurance. And if your child is screaming bloody murder, it may feel a lot easier just to give in to whatever is demanded.  However, if things are too easy and comfortable at home, the anxious avoidance is powerfully reinforced. And then there is little incentive for the child to get out of her comfort zone and challenge herself. Accommodation to anxious behavior can take many forms, from indulging a child’s need for  reassurance,  to buying excessive amounts of soap for a child with germ concerns, or not making them go to school. And because it runs against our natural inclination not to provide comfort to our distressed children, most parents of anxious children have done some reinforcing of anxiety by being overly helpful. However, that does not mean giving free rein to the feelings of impatience or irritation that having an anxious child can create. Yes it is pretty frustrating for your child to have a temper tantrum just because you need to go to a clothing store. But that doesn’t mean that a get tough policy (“we have had enough of your games!”) is appropriate or effective. In fact it will probably make things worse because in the potential power struggle that follows, the real point of mastering anxiety gets lost in the midst of a parent-child battle of wills. Rather, think in incremental terms of how to decrease your accommodating actions, so that the child can adapt slowly, not losing sight of the purpose of this change, which is to help him/her be less limited by anxiety.